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Metabolic surgery for treatment of Diabesity- A reality

Bariatric Surgery Blog Metabolic surgery Obesity Surgery Weight loss surgery

 

Dr. Aparna Govil Bhasker

Bariatric Surgeon, Mumbai

 

“A picture speaks a thousand words”.

diabetes care book

In February 2016, the cover page of Diabetes Care, one of the best international journals in the field of diabetes, carried a picture of a surgery being performed in the military hospital in the first world war. This was not only the first time, surgeons featured on the cover of a medical journal, but this entire issue was a special article collection dedicated to “metabolic surgery and the changing landscape of diabetes care”.

Quintessentially, diabetes has been a medical disease, traditionally treated with pills and injections. Metabolic surgery in mumbai for the treatment of type 2 diabetes is a novel concept that has come to fore in the recent years. In 1978, Dr. Henry Buchwald from Minnesota, USA defined metabolic surgery as the operative manipulation of a normal organ or organ system to achieve a biological result for potential health gain [1]. Today, the term metabolic surgery is typically used to describe surgical procedures to treat type 2 diabetes and other components of metabolic syndrome.

Though the concept is not very new and has been around for about 30 years now, medical community has been very slow to warm up to the idea of metabolic surgery. Way back in 1995, Sir Walter Porries from USA, published a provocative paper – “Who would have thought it? An operation proves to be the most effective therapy for adult onset diabetes” [2]. In the same year-“metformin”, the wonder drug of diabetes treatment was discovered. While metformin went on to be the most commonly used drug in the diabetes spectrum, metabolic surgery still remains one of the most underutilized treatment option. 

Lack of proper evidence has been cited as one of the reasons for the slow uptake of metabolic surgery. In addition to all the other evidence, in the recent years we have level 1 evidence in the form of eleven randomized controlled trials that have compared metabolic surgery with best medical management in overweight and obese patients. One hundred percent of these studies have shown that when it comes to over weight and obese patients, metabolic surgery is far superior in achieving glycaemic control [3]. In 2015, an Italian researcher compiled results of metabolic surgery in more than ninety thousand diabetic patients. In this study more than 71% diabetic patients achieved remission after metabolic surgery [4]. By remission, I mean that these patients had normal fasting blood glucose and HbA1c levels despite no medications for at least one year. Metabolic surgery has also been shown to lead to a significant improvement in high blood pressure and patients are six times more likely to reduce ≥ 30% of their blood pressure medications after surgery [5]. It is needless to say that metabolic surgery leads to an improvement in metabolic and inflammatory profile and decreases the long-term cardio-vascular risk in this patient population. With data and results available for almost one hundred thousand obese diabetic patients, I think it is time that we put the argument about lack of evidence to rest.

In 2015, a landmark meeting was held in London where 48 international scholars came together and formulated guidelines for metabolic surgery. It is important to note that out of 48, 75% of the voting delegates were non-surgeons. The voting panel mainly consisted of diabetologists, endocrinologists and physicians along with a few academic surgeons. These guidelines have been endorsed by 54 international societies across the world, many of which are diabetes societies. Diabetes India is one of them [6]. In 2017, the American Diabetes Association (ADA) accepted these guidelines as an integral part of management of type 2 diabetes [7].

The ADA guidelines for metabolic surgery are as under:

  • Metabolic surgery should be recommended to treat type 2 diabetes in appropriate surgical candidates with BMI ≥ 40 kg/m2 (BMI ≥ 37.5 kg/m2 in Asian Americans), regardless of the level of glycemic control or complexity of glucose-lowering regimens, and in adults with BMI 35.0– 39.9 kg/m2 (32.5–37.4 kg/m2 in Asian Americans) when hyperglycemia is inadequately controlled despite lifestyle and optimal medical therapy.
  • Metabolic surgery should be considered for adults with type 2 diabetes and BMI ≥ 30.0–34.9 kg/m2 (27.5–32.4 kg/m2 in Asian Americans) if hyperglycemia is inadequately controlled despite optimal medical control by either oral or injectable medications (including insulin).

The ADA also acknowledged that obesity management delays the progression of pre-diabetes to diabetes and is also beneficial in treatment of type 2 diabetes. They also said that modest weight loss reduces the need for glucose lowering agents.

Despite great results, presence of evidence and guidelines from the ADA, metabolic surgery is not even being performed for 1% of the eligible patient population who stand to benefit from this. I believe that the biggest reason for this is lack of awareness. People are still not aware about the potential benefits of this therapy. I agree that surgery comes with a risk of anaemia, calcium and vitamin deficiencies but these are preventable with a good follow up and team approach. The advent of laparoscopy has reduced the mortality rate by ten folds as compared to open surgery and the overall complication rate after a Roux-en y gastric bypass is about 3.4% which is about the same as that of a gall bladder or a knee surgery. It is up to us to choose the trade off between preventable nutritional deficiencies and a low complication rate after surgery with potential complications of remaining obese and diabetic in the long term. Given a choice I would rather have my patients on multi-vitamin, iron and calcium supplementation rather than being on insulin or in worse cases kidney transplants, angioplasties, amputations etc.

There is also a contention that even after metabolic surgery, the weight along with diabetes comes back after a few years. Approximately one-third of the patients do experience a relapse or recurrence after a median 8.3 years. I would say that this is not bad at all. 8.3 years of disease-free interval has the potential to yield significant long-term cardiovascular benefits. Metabolic surgery is not an absolute “cure” but it does buy the patient almost a decade of good quality of life and has the potential to push back the expected complications of diabetes.

In conclusion, metabolic bariatric surgery in mumbai is a powerful tool for the treatment of obese diabetics. There is a substantial body of evidence that is showing that surgery on the GI tract yields better glycemic control in this patient population as compared to medical management alone. The role of gut in diabetes is being studied and is a hot topic across the world. Hopefully we shall have some tangible answers in the near future to explain the mechanisms behind diabetes remission after surgery. In the meanwhile, the medical community needs to break down walls and start building bridges so that the best possible therapy is advised to the patients. It is important to be cognizant of the burden that this burgeoning epidemic of diabesity is adding to our healthcare system. Diabetes and obesity are a deadly combination and although we cannot guarantee a cure, we can atleast endeavour towards getting a better glycemic control and quality of life. Metabolic surgeons and diabetologists/endocrinologists need to work in conjunction to provide the best treatment options to their patients.

Although it is true that ultimately it is He who heals, we as doctors must give our best to our patients.

 

References:

  1. Buchwald H. Metabolic surgery: a brief history and perspective. Surg Obes Relat Dis.2010 Mar 4;6(2):221-2.
  2. W J Pories, M S Swanson, K G MacDonald, S B Long, P G Morris, B M Brown, H A Barakat, R A deRamon, G Israel, J M Dolezal. Who would have thought it? An operation proves to be the most effective therapy for adult-onset diabetes mellitus. Ann Surg. 1995 Sep; 222(3): 339–352.
  1. Viktoria L Gloy et al. Bariatric surgery versus non-surgical treatment for obesity: a systematic review and meta-analysis of randomised controlled trials. BMJ 2013;347:f5934
  2. Panunzi S, De Gaetano A, Carnicelli A, Mingrone G (2015). Predictors of remission of diabetes mellitus in severely obese individuals undergoing bariatric surgery: do BMI or procedure choice matter? A meta-analysis. Ann Surg 261:459–467
  1. Schiavon CA, Bersch-Ferreira AC, Santucci EV et al. Effects of Bariatric Surgery in Obese Patients With Hypertension: The GATEWAY Randomized Trial (Gastric Bypass to Treat Obese Patients With Steady Hypertension). 2018 Mar 13;137(11):1132-1142.
  2. Rubino F, Nathan DM, Eckel RH et al. Metabolic Surgery in the Treatment Algorithm for Type 2 Diabetes: A Joint Statement by International Diabetes Organizations. Diabetes Care.2016 Jun;39(6):861-77.
  3. American Diabetes Association (2017) Obesity management for the treatment of type 2 diabetes. Diabetes Care 40:S57–S63

 

DR. APARNA GOVIL BHASKER- BEST BARIATRIC SURGEON IN MUMBAI, INDIAAbout Dr. Aparna Govil Bhasker

Dr. Aparna Govil Bhasker is an accomplished and renowned Bariatric Surgeon in Mumbai and Laparoscopic Surgeon.

Read more about Dr. Aparna Govil Bhasker- https://www.bestbariatricsurgeon.org/dr-aparna-govil-bhasker/  

Please write in to info@bestbariatricsurgeon.org or draparnagovil@gmail.com & Call/Text/WhatsApp: +919819566618 or +919930922761

Dr. Aparna’s website is- https://www.bestbariatricsurgeon.org

You can read her lovely blogs on- https://www.aparnagovilbhasker.com

Dr. Aparna Govil Bhasker is a visiting consultant at the following hospitals:

  • Gleneagles Global Hospital, Parel, Mumbai
  • Surya Hospital, Santacruz West, Mumbai
  • Hinduja Healthcare Surgical, Khar West, Mumbai
  • Apollo Hospital, CBD Belapur, Navi Mumbai
  • Suchak Hospital, Malad, Mumbai
  • Namaha Hospital Kandivali, Mumbai
  • Currae Specialty Hospital, Thane
  • MGM Hospital, Vashi, Navi Mumbai
  • Apollo Spectra Hospital, Tardeo and Chembur, Mumbai
  • Saifee Hospital, Mumbai

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Using bariatric surgery to fight obesity

Using bariatric surgery to fight obesity

Bariatric Surgery Blog Obesity Surgery Weight loss surgery

Dr. Aparna Govil Bhasker
Bariatric and Laparoscopic Surgeon

In the last week amongst the other patients I saw, there was one with a history of a stroke a few days back, one with a history of stroke, 2 years ago and a young lady with a condition called intracranial hypertension.

The one common factor between all three patients was, that all of them suffered from morbid obesity or clinically severe obesity, as it is called now.

The thing about obesity is that it is wrongly perceived as a sign of good health and a well to do economic status, atleast in India. However once people crossover from the overweight to the obese category, which is somewhere around a BMI of 29 to 30 or so, they tend to put on weight faster.

As the BMI continues to increase, obesity gradually starts affecting each and every part of the human body. Diabetes, high blood pressure and dyslipidemia are the big three that alongwith obesity form the metabolic syndrome. Eventually these together increase the risk of having cardiovascular events. Stroke is one of them.

Coming to the treatment part. Bariatric surgery is recommended for patients suffering from clinically severe obesity if their BMI is greater than 35. It can also be considered as a treatment option for patients with a BMI more than 32.5 with two or more associated diseases. As of now it is the only valid treatment option that leads to sustained weight loss in this patient population.

As a bariatric surgeon, I see many such patients on a daily basis. I also usually see that these patients and their families are very scared of getting the surgery done. There are many myths and many detractors who prevent these patients from getting treated on time.

Now here is the thing about treatment of any disease. Firstly, one needs to recognize that he or she is suffering from a disease. Secondly, get one or may be two expert opinions from qualified professionals and specialists about the best way forward. Thirdly, plan the entire process, prepare well and get it done. Last but not the least, dont delay the treatment. Every treatment works best in the early stages of a disease. Every single day that you delay, you are allowing the disease, time to grow and decreasing the chances of curing it.

Problems like stroke, heart related issues, embolism etc are life threatening complications of obesity. Dont let it grow to this extent.

Getting timely treatment can save your life and also improve your quality of life. Consult the right doctor at the earliest. Please dont miss the bus.

Dr. Aparna Govil Bhasker
Bariatric and Laparoscopic Surgeon

HEALERS OF A BROKEN SYSTEM

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© Dr. Aparna Govil Bhasker

When Chandrayan 2 fell short of just one more mile, from making history, no “failure” could be proclaimed to be more “heroic” than that. A true leader, the honourable Prime Minister, went out of his way to support our scientists and said that there is “no failure in science, it is a journey and one or two difficulties must not hold us back”. The entire nation stood behind ISRO like never before, and rightly so. It was a perfect example of embracing failure, expressing our solidarity with our scientists and a beautiful lesson in forgiveness. It was humane and graceful and makes me feel proud of my countrymen and women. On a lighter note, it was the hug of the century.

However, in the current times, when it comes to “failure in medicine”, it is neither heroic nor graceful. As a profession medicine is one of the most, “failure averse”. From our early days in medical school, we doctors are indoctrinated with the mantra that, “failure is not an option”. The paradox however is that, in life, failure is inevitable and the medical profession is no exception to this. As doctors we fight the toughest battles with the two of the biggest enemies of mankind- disease and death. To say the least, nothing can be more humbling and as we grow in experience we learn the lessons in humility the hard way.

So, first and foremost, why are we doctors, so hard on ourselves? Most of us have immense difficulty in accepting that despite best efforts, sometimes things may not go our way. Though we are taught lessons in detachment, are we really able to practice them? No one has ever escaped death, but when it happens on our watch, we feel the burden of the lost life on our fragile shoulders. Unfortunately, no amount of money can snatch away a loved one from the clutches of disease and death. As doctors, sometimes even we are guilty of suffering from the God complex. At times we ourselves tend to forget that we are only human at the end of the day.

Doctors and patients are two sides of the same coin. Let’s flip the coin and see it from the patient’s perspective. From time immemorial patients have reverred doctors next only to God. There is an extremely strong emotional element that is associated with the practice of medicine. Unlike other service industries, healthcare can never be proportionate to the amount of money paid. An x amount of money may guarantee you a business class seat in an airline or the best suite in a seven star hotel, but no amount of money can guarantee getting good health back. Money is just a way to define value for a service, but in case of healthcare it falls severely short. Money is never enough to make up for the loss of a loved one, and neither is it enough to compensate a doctor for saving a loved one. But until we have another way of valuing the services of doctors and healthcare, money will be the third prong in the wheel. I am not an economist, but I dont need to be one, to know that most people in this country are barely able to make ends meet. We may be close to eradicating polio, but we are nowhere near eradicating poverty in this country. India is a country with a burgeoning population and, in the absence of solid universal health coverage and public health institutes falling severely short, the burden of dealing with a disease and its treatment falls on individuals. A burden they probably cannot carry. I dont feel proud when I say that India has one of the lowest healthcare budgets in the world. Indian citizens are deeply dissatisfied and disappointed when it comes to the basic human right of being provided with good healthcare. Private healthcare is expensive and like all businesses the goal is to make profits. In an emergency, when public healthcare is not an option people turn to private healthcare, which unfortunately is unaffordable for most. And when expectations are not met, it leads to friction and sometimes escalates to violence.

For ages, Indian doctors have held a broken healthcare system together and have done a great job of it. Success stories of everyday never make head line news but what we have achieved in the realm of healthcare with our “meagre resources” is nothing short of a miracle. However, it certainly is not enough for a country with 1.37 billion people. Doctors are the face of medicine and while they are the foot soldiers who are fighting this battle with minimal support, they are repeatedly facing the ire of dissatisfied masses. Every other day, we hear of doctors being abused and hospitals being vandalized. Impatience has become the hallmark of today’s society. While the world becomes smaller and digital, we need to understand that we are still eons away from curing diseases of the complex human body with a click of a button or by using artificial intelligence.

Today, there is increasing dejection and demotivation amongst healthcare practitioners and doctors. Doctors are also citizens of this great country and it might help our morale if we received some grace too. For us, every patient is precious and we succeed more often than we fail. Death is invincible, but doctors are the only ones in this world who dare to fight it. If not a hug, atleast we don’t deserve to be chided by our dear Prime Minister time and again and be beaten up for failures that may sometimes be out of our control. It is our sincere appeal to the government to increase the healthcare spends in the upcoming budget and show some positive inclination towards supporting the Indian citizens for this basic human right that is “health”.

Dr. Aparna Govil Bhasker is a Bariatric and Laparoscopic surgeon practicing in Mumbai. Alongwith Dr. Debraj Shome they have published the iconic book “Dear People, With Love and Care, Your Doctors”, which is an anthology of short stories set in the healthcare environment. The book has consistently been in the top 10 best sellers list and is in its 4th reprint already, within four months of being released. To know more about the book, click on http://www.dearpeople.in

YOU ONLY LIVE ONCE YOLO

YOU ONLY LIVE ONCE “YOLO” ??

Blog HerStory

-Dr. Aparna Govil Bhasker

I wake up every morning and without fail, spend atleast ten painstaking minutes standing in front of my wardrobe thinking what to wear. And every single day, for as many years as I can remember, I have been plagued by this one thought-

“I dont have enough clothes (translates to shoes, accessories, jewellary etc etc)!”

My husband ofcourse has a starkingly different opinion on this but I guess like all other husbands in successful marriages he has mastered the art of ignoring certain things. Works better that way ?!!

A shopaholic by my own confession, my dedication to shopping sometimes extends into 4.00 am shopping sprees at airports. For me it forms for a fabulous start to a great day ahead. I have this innate ability to be able to shop anywhere, anytime… Much to my husband’s chagrin, I still have no qualms about picking
up stuff from the local stores of Hill Road, junk jewellary from the Colaba causeway or footwear from the Linking road. I have the same zeal and dedication when I buy stuff from a village in Rajasthan or from a branded store in Mumbai. I love to bargain with local shop-keepers and to be honest I still haven’t gotten over the embarassing habit of looking discreetly at the price tags in the high end stores!

Just passing by a crowded market area is enough to elevate my mood. My mother often tells me that what I buy will not last me very long… and I am like, “Mom, that’s exactly why I bought it! I don’t want it to last too long!” Afterall, variety is the spice of life. I dont want to wear the same pair of shoes for 2 years.. I would rather have a new set every few months!

Since I started earning myself, I allocate a monthly budget exclusively for myself. Its not much but its enough to make me happy. I disagree with the common perception that happiness is difficult to find. Nothing elevates my mood more than finding something that I like. Shopping works like a drug for me! The world is cruel at times but the mall always has a healing effect! Lol!

As I grow older, I realize that pampering myself is an important aspect of life. An extra shade of lipstick, a new pair of earrings, an extra pair of shoes, one more book on my shelf or new cup for my coffee does wonders for me!

As women, pampering others comes more naturally to us than the other way round. Most of us have to work hard at learning to love ourselves. All I have to say is that there is only one life we all get… We all struggle for the big things in life, in the process don’t give up on the small pleasures (even if they are a little materialistic by worldly standards… lol). Ultimately happiness is not a goal that we will achieve one fine day in the future, it is a continuous phenomenon. It is a drug that we need on a daily basis, to go on.

All of us have that one thing that makes us happy, and the trick is to identify it. We all need our drug. Make an effort towards finding your drug and learn to pamper yourself a little sometimes, for life is short and you only live once (YOLO ??).

–Dr. Aparna Govil Bhasker

Cadaver- A Surgeons First Teacher

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Dr Aparna Govil Bhasker MS,

Bariatric and Laparoscopic Surgeon, Mumbai, India

 

The business of saving lives begins in the company of death. For most of us something changed the moment we walked into the anatomy dissection hall on the first day of our medical training. It is a surreal experience, frightening and fascinating at the same time. We spend the best decade of our lives to learn how to repair wounds, how to heal a body, how to make it whole again. On day one of our medical career the cadaver teaches us that we can only try our best and eventually there may be some wounds that we may not be able to repair and some bodies that we cannot heal. As it lies on the dissection table surrounded by a bevy of zealous and fervent medical students, a cadaver teaches us the first and the most important lesson that “Doctors are not God”.

In the 3rd century BC, the city of Alexandria was home to two physicians- Herophilus and Erasistratus who defied the law and dissected human corpses to clear many misconceptions about the human body. They eventually fell into disrepute as reports of dissection by them on live prisoners started coming in. Although it was banned for centuries in many regions of the world, cadaver dissection has been integral to anatomical and surgical research. From Leonardo-da Vinci to Michael Angelo, many renowned artists attended dissections to understand nuances of the human body and went on to publish their drawings to add to the anatomical literature.

Surgical training is at a tipping point today. The advent of surgical simulators, computer modeling, animal and human dummies, free availability of surgical videos on platforms like you tube and other online libraries have provided training avenues like never before. Yet when a young surgeon wields the scalpel for the first time, his hands are shaky and that first cut invokes a combination of both dread and awe. No simulator or app can mimic the complexity of human anatomy and tissue fidelity.

Like most other branches of medicine, surgery is an ever evolving field. It is about learning the technique, practicing it and eventually mastering it. Every few years there is a paradigm shift and we as surgeons need to constantly update and upgrade ourselves with the newer technology. Most of us learn these techniques from the experts and eventually end up practicing on our unassuming patients. The process is not only unfair to our patients but is also painfully long and most of the times it takes years for a surgeon to be confident of her/his skillset. A surgeon has to be on her/his “A-Game” every time she/he walks into the operation theater and no other specialty in the medical profession demands as much precision and commitment as surgery. 

In the recent years cadaver labs have emerged as a useful and effective method for surgical training. Spatial perception of anatomy is one of the biggest advantages that a cadaver offers over any other training modality. It also helps surgeons to practice new techniques in a safe environment before performing on a live patient and cadaver training can benefit all surgeons from the trainee level to the more experienced consultants. In an ideal world, surgery training would probably include practicing surgical procedures on cadavers to become proficient before operating on live patients.

Unfortunately there is a perpetual shortage of cadavers in most parts of the world and body donation is a challenge almost everywhere. Most cadaver labs rely on unclaimed bodies and however gory it may sound, grave digging still thrives as a business in some places.

In a country like India, cultural and religious reasons prevent most people from donating their bodies for medical advancement. M S Ramaiah Institute in Bangalore was the first to start a cadaveric research and training unit in India. Recently Amrita institute of medical sciences in Kochi was the second Indian institute for initiating training courses on cadavers. Now we have a few more. However, the acceptance is very slow and these institutes constantly grapple with shortage of cadavers.

The east and the west have devised two very different approaches to tackle this issue of body donation. My first experience of a cadaver lab was at the Chula Surgical Training Center in Bangkok, Thailand set up in 2007 by Dr. Suthep Udomsawaengsup. Equipped with 48 state of the art working stations, multiple training workshops are conducted round the year at this lab.

Till 30 years ago, Thailand was struggling like any other country to acquire cadavers. Today most cadavers are acquired through voluntary un-remunerative donation. Body donation is considered as the highest form of donation. Not only is it approved by the King, donors are also bestowed with the highly regarded status of “ajarn yai” or the “great teacher”. Unlike the west which treats the cadaver as the “first patient” the east regards it as the “first teacher”. The other difference is that the west lays more focus on emotional coping and the east primarily focuses on forming a relationship with the new teacher. The west thrives on anonymity whereas in the eastern culture training starts with the introduction and life history of the cadaver that was once a person [1].

Medical University of Vienna is well known for its hands on courses on fascial aesthetic surgery and dental implant surgery on fresh cadavers. Unlike Asian countries, most European countries have an “opt out” program for organ and body donation.  Donation occurs automatically unless a specific request has been made prior to death. The “opt out” system works better 

for obvious reasons and the rate of organ and body donation is higher in countries that practice this system.  Hesitancy to discuss regarding their death, religious reasons and a gap between intent and action are the primary reasons for failure of the “opt in” system most of the times. 

Solo surgery time is a landmark day in the life of every surgical resident. We slog day and night, for that one moment when we would be allowed to operate on a patient independently. It’s a different high, to have another fellow being’s life in our hands, to be in total control. Great power comes with greater responsibility and what we cannot afford is………..to make a mistake. Errors in surgery can prove to be devastating for the patient as well as the surgeon. Training is the key to minimizing these errors and in future cadaver labs will play a significant role in surgical training. Surgery cannot be learnt from books alone and as the French anatomist Marie François Xavier Bichat once said- “Open up a few corpses: you will dissipate at once the darkness that observation alone could not dissipate”

 

References

  1. Andreas Winkelmann, Fritz H Güldner. Cadavers as teachers: the dissecting room experience in Thailand. 2004 Dec 18; 329(7480): 1455–1457.

Acknowledgements

  1. Dr Suthep Udomsawaengsup – King Chulalongkorn Memorial Hospital, Bangkok, Thailand
  2. Dr Ajjana Techagumpuch- King Chulalongkorn Memorial Hospital, Bangkok, Thailand
  3. Dr Debraj Shome – Breach candy and Saifee hospitals, Mumbai, India
BARIATRIC SURGERY – Should Children Have It

BARIATRIC SURGERY – Should Children Have It

Bariatric Surgery Blog

Dr. Aparna Govil Bhasker

Bariatric and Laparoscopic GI Surgeon,

Global Hospital, Parel; Apollo group of hospitals, Currae hospital, Thane; Namaha and Suchak Hospitals, Kandivali and Malad

It is widely believed that the cohort of children born in the year 2000 in the USA, may live sicker or may not outlive their parents. With 19.3% of Indian children being either overweight or obese, we too are staring into an epidemic of childhood obesity.

In the Indian context a “chubby” child not only signifies good health but also good parenting. While it is true that genetics load the gun, it is the environment that pulls the trigger. In the vast majority of obese children, the cause for weight gain is polygenic and environmental. Monogenic obesity such as that caused by leptin deficiency is extremely rare and is seen in less than 1% of obese children.

Obese children tend to suffer from various health consequences like type 2 diabetes, obstructive sleep apnea, hypertension, dyslipidemia, fatty liver and so on. Till 30 years ago it was rare to see type 2 diabetes in children, but today children as young as 8 years are turning diabetic. Unfortunately, the changes these chronic diseases bring are irreversible and even if these children go ahead and lose weight as adults it leads to permanent damage to their blood vessels and other organs like kidneys, liver and heart. Apart from the physical changes, they also have serious self-esteem issues and tend to get isolated from their peers. 

Treatment options for childhood obesity largely include diet and lifestyle modification and pharmacotherapy in some instances. Success of bariatric surgery for treatment of adult obesity has led to a gradual surge in bariatric surgery cases being performed on obese children over the last few years. Bariatric surgery includes a variety of surgical procedures like gastric banding, sleeve gastrectomy, Roux-en y gastric bypass and duodenal switch. These are performed laparoscopic or by open method.

A couple of years back the International Journal of Surgery published a case report about a two years old toddler becoming one of the youngest patients to undergo weight loss surgery at a hospital in Riyadh, Saudi Arabia. This toddler underwent a laparoscopic sleeve gastrectomy surgery, wherein two thirds of the stomach was surgically removed. The report was published 2 years after the surgery was conducted and the child had lost about 10 kg in 24 months (an average of 0.4 kg per month).

This report was widely publicized in tabloids across the world and had generated a lot of media frenzy. Although most cases of bariatric surgery on children and toddlers are presumably performed as life-saving procedures; the overzealous media hype around them is worrisome. This overenthusiastic excitement borders on unreasonably coercing bariatric surgery as being a standard of care for obese toddlers and children, even in the absence of any hard evidence. These cases raise a lot of pertinent questions, not only about the future medical and psychosocial outcomes in these children, but also about medical ethics and moral accountability.

Most bariatric surgery procedures lead to a significant reduction in the levels of “Ghrelin” hormone. It has been proven that ‘Ghrelin’ plays a significant role in secretion of the growth hormone and is an important link connecting growth and body composition with metabolism. This reduction in Ghrelin levels can have unknown repercussions on the growth.

Bariatric surgery is also known to cause bone loss and osteoporosis in children. Nutritional deficiencies are known to occur after surgery, and to expect lifelong commitment in terms of nutritional supplementation from a toddler may be too much to ask for. The implications on future reproductive health and pregnancy outcomes are also unknown.

Direct extrapolation of adult results to pediatric population has not worked in the past and may not work in these case too. Moreover, an average weight loss of half a kg per month, can possibly be also achieved by implementation of a strict medically supervised lifestyle modification. These children are too immature to understand the gravity of the surgery being performed on them. For many years to come, they will not be able to apprehend the demands and exigencies of a bariatric procedure. It may be overzealous to perform this on children, who may be at risk of experiencing unanticipated negative consequences several years into the future. It is also not justifiable to surgically modify healthy organs of an innocent toddler in absence of any clear evidence regarding safety and future outcomes.

Another question that arises here is, ‘Who exactly are we treating?’

We would expect that parents would act in the best interest of their children, and usually, they are the ones who would take the decision and give consent for surgery. Poor parental food choices are a significant contributing factor leading to a rise in childhood obesity. More often than not, in such cases, we are probably actually treating the parental guilt rather than the health of the children in question. Surgery may be just a convenient solution to what may be perceived as parental failure.

As parents and doctors, we have a huge responsibility when it comes to the future of our children. Extreme caution is warranted while treating such cases. Prevention is certainly better than cure. Childhood obesity must be taken very seriously. We need to cultivate healthy eating habits in children and there must be regular health campaigns focused at prevention of obesity. Some of these severely obese children may be suffering from a genetic cause for obesity and must be evaluated and treated accordingly.

Cutting into a child’s healthy organ as a quick-fix must be avoided at all cost; and doctors and hospitals must refrain from generating unwarranted media hype around these cases. It is high time that the right perspective is brought to the forefront. Bariatric surgery must not be confused as being a standard of care for treatment of severely obese children. Even in cases where there is no other choice, a multidisciplinary team must look into all aspects before reaching to a decision and surgery must be performed with extreme caution. Bariatric surgery in children must be reserved only as a last resort when all other options have been exhausted and the choice is between life and death.

Dr. Aparna Govil Bhasker - Best Bariatric surgeon in mumbai, india

I AM A PERSON, NOT JUST A PHONE NUMBER

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©Dr. Aparna Govil Bhasker

Come December and its the season of weddings. Be it DeepVeer, Nickyanka or the Ambani extravaganza, this year it seems to be unending. Social media has gone into a frantic frenzy with hundreds of shared images of exquisite wedding locales, star studded finery and mouth watering quisine! …..You can’t blame me from feeling a tad jealous of our dear, Sabyasachi! The man can practically retire now with enough savings for the next three generations! …..Having said that, if I am subjected to viewing anymore WhatsApp videos and pictures of weddings, I will probably start pulling my hair off!

Talking about the unfairness that life bestows upon us, the luck of a good looking but written off heir has suddenly turned around and jitters are being felt all over. Even Lord Ram himself could not prevent this from happening! The half blood prince has defied the odds and it looks like the tug of war has just become a wee bit more difficult. Well, luck does favour a few, however it seems like the political discussions have shifted base from being living room conversations to WhatsApp group conversations with members being divided into different camps… Unfortunately, more often than not, it hardly takes any time for these conversations to transform into acrimonious arguements. Social media lets you hide behind the anonymity of your phone and somehow it is always easier to be rude to a “message” than to a person.

And while most of us lowly mortals have to employ agencies to beef up the following of our social media accounts, there is a star baby that has become an instant internet sensation and has more than a million instagram followers who ogle at his every move! Mind you the following is consistent for over a year which is almost as long as he has been on this earth! Ofcourse this is the aspiration that parents must set for their newborn babies! Being a social media celebrity carries more significance today than getting good grades in school! Who cares if your kid has topped the class or won a difficult debate. The paradigm has shifted and today success is judged on the basis of totally different parameters.

So what is it that I am getting at? We all are aware that media is one of the least trusted institutions in the history of mankind. We already know that whatever the media feeds us has to be taken with a pinch of salt.

However, what about social media? In my mind social media is the true reflection of the society that we live in. While conventional media shoves things down our throats, social media is what we “want” to see….

Unfortunately, today I dont see much difference between what is shown to us and what we want to see. And that is the concerning bit. We are so taken with the irrelevant, that most of us are forgetting what is relevant to us. We spend hours scrolling on our phones looking at stuff that is of no significance. We ogle and quibble incessantly about insignificant trivia. We feel compelled to respond and react to stuff thay may or may not concern us directly. Our ability to express an uncensored opinion obviously boosts our ego and gives us a false sense of importance.

In times to come, I guess self restraint will be an extinct quality and all we will get to hear is incomprehensible noise.

There is no doubt that social media is powerful and just like every other powerful medium, it can go both ways. Potential for good is as high as potential for harm. With great power comes great responsibility and this time the onus lies on us. Lastly, I pray that while social media continues to rule our lives, we stop treating people as just a “number” and begin to look at them as a “person” once again.

©Dr. Aparna Govil Bhasker

DOCTOR WE TRUST YOU! ©Dr. Aparna Govil Bhasker

DOCTOR WE TRUST YOU!

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©Dr. Aparna Govil Bhasker

As the year comes to an end, we finally wrapped up writing, editing, rediting and re-re- editing our book on doctor- patient relationships. Oh no…dont get me wrong! This is not a promotional post! Those will come later :), closer to the release, and there is still some time for that!

However, as we spent hours researching facts and hard data on doctor patient relationships, one fact that really struck me very deeply was that 92% of patients “trust” their doctors! For more than 25 years, medical professionals have topped the charts by being the most trusted profession of all. People trust their doctors more than they trust teachers, judges, engineers, professors and lawyers…… Need I say anything about media, government, politicians and advertising? I dare not…. I can just blame it on the data! Lol ?
©Dr. Aparna Govil Bhasker

In this era where negative news sells like hot cakes and probably rakes all the moolah, positive news tends to get buried under the weight of all the negativity. No one is interested in the positive. Positive ofcourse is boring. Which newspaper would like to publish that today 10,000 patients underwent successful medical treatment in the city of Mumbai! Is that even news? No way…But ofcourse they would jump on- “one patient had a complication” or “one doctor screwed up” or “xyz sues abc”. That is interesting and that makes people buy newspapers and watch news channels!

Coming back to the core issue of doctor patient relationships. Today a lot of patients think that doctors are predators. Infact some doctors also think that doctors are predators! Well……what can I say to that……….On the other hand, a lot of doctors view every new patient as a prospective litigant. No one can blame us for being defensive because afterall, tomorrow we may get sued for some rare test that we didnt order. ©Dr. Aparna Govil Bhasker

However, the fact that more than 90% of the patients still trust their doctors places us at a very important “Y” junction. I think this is the time to initiate a conversation. Not every doctor is a predator and not every patient is a potential litigant. In day to day life, doctors and patients generally share a beautiful relationship. Most of us doctors, enjoy conversing with our patients, some of our patients become our best friends, we wake up to messages filled with heartfelt gratitude and most us have the talent to connect with others easily. As for patients, most of them have high regards for their doctors, they share their darkest secrets with us and trust us deeply. Afterall they place their lives in our hands. Having said that, even though this is a transactional relationship and there is a fee to service, no amount of money can ever be equated with the value of life and the weight of responsibility on the doctor’s shoulder.

In the recent years, morale in the medical community has been at its lowest. There have been increasing incidents of assaults on doctors, hospitals being vandalised and all kinds of violence pervading into our system. Politicians (including you know who!) and media have just added fuel to the fire. ©Dr. Aparna Govil Bhasker

Doctors today have the highest rate of depression and suicide. Burn out rate amongst medical residents is one of the highest in the world. We probably are the only profession made to feel guilty about charging a fair fee and have to justify it every single time. Most doctors I know and that includes myself, do not want their next generation to be a doctor. ©Dr. Aparna Govil Bhasker

So, where are we heading in 2019? Are there any solutions to these questions. In my mind the solution is evident. I agree that their are outliers amongst doctors and patients but more than 90% of doctors are good doctors, and more than 90% of patients, trust these good doctors.

Need of the hour is to generate more positivity from both the sides. Somewhere the tracks have to converge and a conversation needs to be initiated. Fear of laws can only help us temporarily but ultimately the behaviour of people is reflective of the society they live in. It is heartening to see such reports and it gives us hope that the present and the future are not as bad as they are made out to be. Just like patients are looking for doctors they can trust, doctors are also encouraged when patients trust them. I hope and pray that the new year brings a fresh wave of change and positivity. This shall not be a twain that will never meet!

©Dr. Aparna Govil Bhasker

Ref: IPSOS Mori veracity index 2018

#doctorpatientrelationship

weightloss diet in mumbai, india

Quality versus Quantity Nutrition

Bariatric Surgery Blog Diet Obesity Surgery Weight loss surgery

Author- Mariam Lakdawala (Registered Dietician)

Common questions I generally get from my patients suffering from obesity,

“I don’t eat much, still why am I gaining weight?”

“I eat less than one of my friend, but why is she so thin and I am not?”

My answer to such questions is simple, “Don’t only see how much is on your plate, but also see ‘what’ is on your plate”.

The basic rule of weight loss is to restrict the overall quantity of food and increase the calorie burning capacity of the body. However, this rule has been outdated as only quantity restriction in the absence of food quality management, will not result in positive weight loss outcomes. Also a good quality diet which consists of good quantities of proteins and fiber keeps you full for longer and delays the intake of subsequent meal.

Though factors like genetics and heredity play a major role in adding those kilograms, ‘food’ can also be a major factor for tipping the scales towards obesity. If the quality of the diet is poor, food becomes the major cause of obesity. Your food plate determines the quality of your meals. An ideal food plate must have all the major (macro) nutrients i.e. carbohydrates (also includes fiber), proteins and fats in correct proportions.

weight loss diet in mumbai, india

In India, our diet is rich in carbohydrates with very less quantities of vegetables and proteins. This has an adverse impact on our metabolism and exposes us to various metabolic diseases, including obesity. In metropolitan cities the dependence on ready to eat processed foods like biscuits, breads, noodles, sausages/ nuggets etc is much higher in order to save time. These processed foods are generally high in sugars, salt and fat which makes them less nutritious and dense with empty calories. Poor quality diet coupled with lack of physical activity just makes it worse and has played a big role in increasing obesity levels.

The quality and quantity of food are two sides of the same coin. Both the aspects are equally important not only for weight loss but also for maintaining good health and must not be ignored.

Hypoglycemia

How to manage Reactive Hypoglycemia?

Bariatric Surgery Blog Gastric Bypass Gastric Sleeve Obesity Surgery Weight loss surgery

Author- Mariam Lakdawala, Registered Dietician

The most common observation made among diabetic patients is that they generally grab on sugar or sugary beverages when they get hypoglycaemic (a drop in the blood sugar levels). But are these sugar shots really helpful?

Temporarily – yes, but after 2-3 hours there are higher chances of experiencing another episode of Hypoglycemia. This kind of meal or rather simple sugar induced Hypoglycemia is known as Reactive Hypoglycemia. After the ingestion of sugar/ sugary beverages there is a rapid increase in the insulin secretion. Insulin causes a rapid digestion and absorption of sugars and still remains in the blood eventually causing low blood sugar levels.

The symptoms include dizziness, fatigue, light headedness, sweating, irritability, confusion, blurred vision, heart palpitations, etc.

Here are some dietary tips to prevent and manage reactive hypoglycaemia,

  1. Avoid consumption of sugar, honey, jaggery, processed foods, bakery products (bread/ biscuits/ cookies/ toast/ khaari/ butter, etc).
  2. Add fiber rich foods like vegetables, pulses, sprouts, fruits to every meal in order to improve the quality of carbohydrates.
  3. Do not keep long gap between the meals. Eat a small snack in between the main meals.
  4. Ensure every meal is balanced with good quality proteins from milk, curds, paneer, soy and its products, egg, fish, poultry, meat, etc.

Reactive hypoglycaemia could be because of multiple other reasons (Eg. Post gastric bypass surgery) and can be managed with the same dietary modifications. In case it doesn’t resolve with the diet, you can check with your doctor for further medical management.